r1r STANDING COMMITTEE ON RULES OF PRACTICE - Maryland ...

If you or your child are members of or are eligible for
membership in an Indian tribe, as defined by federal law, you
have special legal rights under the Indian Child Welfare Act.
You should not sign this consent form if you believe this may
apply to you. You should tell the person requesting the consent
or the court that you believe that your child's case should be
handled under the Indian Child Welfare Act.
L. Authorization for Access to Medical and Mental Health
Records
You may be asked to sign a separate form (authorization) to
allow the adoptive parents and adoption agency to get your
child’s medical and mental health records or your medical and
mental health records. If you agree to allow access to this
information, the records given to the adoptive parents will not
include identifying information about you unless identifying
information was previously exchanged by agreement.
M. Signature, Witness, and Copy
If you decide to complete and sign the consent form, you
must have a witness present when you sign it. The witness must
be someone 18 or older and should not be the child or the child’s
other parent. You must complete and sign the form with a pen and
print or type in your name, address, and telephone number. The
witness also must sign the form and print or type in the witness’
name, address, and telephone number in the blanks on the last
page.
If you have a post-adoption agreement, you must attach a
copy to the signed consent form.
You have the right to receive a copy of the signed consent
form.
STOP HERE IF YOU DID NOT UNDERSTAND SOMETHING YOU HAVE READ OR IF
YOU WANT TO SPEAK WITH A LAWYER BEFORE YOU DECIDE IF YOU WANT TO
SIGN THE CONSENT FORM.
If you wish to sign the consent form, you must also sign here to
verify that you read these instructions and understand them:
____________________________________ _________________________
(Signature) (Date)
You must attach a copy of these signed instructions to the signed
consent form.
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